AN ACT relating to health insurance.
Amend KRS 304.17A-500 to include definitions for "adverse determination", "capitation", "complaint", "life threatening" and to define "complainant" as an enrollee, provider or other person designated to act on behalf of an enrollee; create a new section of KRS 304.17A to require an insurer offering a managed care plan to disclose certain information regarding emergency care services and other services and circumstances when an OB/GYN may serve as a primary care provider in writing, to an enrollee at the time of enrollment and upon request; amend KRS 304.17A-520 to require each plan application form to include a space for an enrollee to select a primary care provider, and specify that a managed care plan may limit an enrollee's request to change providers to no more then four (4) changes in any twelve (12) month period; create a new section of KRS 304.17A to require an insurer that offers a managed care plan to notify a group contract holder within thirty (30) calendar days of substantive changes to a payment arrangement between the managed care plan and providers, to require insurers that offer managed care plans to establish procedures to provide access to a member handbook and the internal system for complaints and the independent review process to an enrollee who has a disability affecting his ability to communicate or to read; create a new section of KRS 304.17A to require insurers that offer managed care plans to establish and maintain an internal system for the resolution of complaints which can be oral or written, to require that the managed care plan acknowledge receipt of the complaint within five days of receipt, to require the managed care plan to investigate and resolve each complaint within thirty (30) days, to require that complaints concerning emergencies or denial of continued stays for hospitalization be resolved within one (1) day from receipt of complaint, to require the managed care plan to issue a response letter to complainant explaining the resolution with specific medical and contractual reasons for the resolution, specialization of the provider consulted, clinical basis, notice of enrollee's right to seek review by an independent review organization, and the toll-free telephone number and address of the Kentucky Department of Insurance, to allow an enrollee immediate appeal to an independent review organization in a circumstance involving a life-threatening condition, to require the managed care plan to maintain a record of complaints, proceedings and actions for three (3) years, and to allow a free copy of the record on the complaint to the complainant; create a new section of KRS 304.17A to allow any person to report an alleged violation to the Kentucky Department of Insurance, to require the commissioner to investigate a complaint against a managed care plan within sixty (60) days; create a new section of KRS 304.17A to prohibit an insurer that offers a managed care plan from engaging in any retaliatory action against a group contract holder, enrollee, or provider who filed a complaint against the managed care plan or appealed a decision of the managed care plan; amend KRS 304.17A-525 to except an enrollee determined to have a special circumstance; create a new section of KRS 304.17A to define "special circumstance" to include a situation where a person has a disability, acute condition, life-threatening illness, or is past the twenty-fourth week of pregnancy, to create an opportunity for the treating provider to continue treatment of the enrollee even if the provider is no longer within the network, to clarify that the obligation of the managed care plan to reimburse the provider for ongoing treatment of an enrollee does not extend beyond the ninetieth day after the effective date of termination or nine (9) months in the case of an enrollee diagnosed with a terminal illness, but for the enrollee past the twenty-fourth week of pregnancy treatment will extend through the delivery of the child, postpartum, care and the first six (6) weeks after delivery, and to establish a payment plan of capitation amount to enrollee's primary care provider; create a new section of KRS 304.17A to establish the Independent Health Care Appeal's Program in the Department of Insurance, to require an enrollee to apply for review within sixty (60) days of the date of the final decision issued by the managed care plan and to require enrollees to include certain information with the application for review; create a new section of KRS 304.17A to require the commissioner to contract with one (1) or more independent utilization review organizations to conduct the independent appeal review, to promulgate administrative regulations regarding certification, selection, and operation of independent review, and to establish procedures and standards regarding the independent review; create a new section of KRS 304.17A to require the independent review organization to state its findings and recommendations in writing, to require the managed care plan to comply with the determination and to pay for the review according to a schedule of fees established by the commissioner; create a new section of KRS 304.17A to establish the certification requirements of an independent review organization; create a new section of KRS 304.17A to allow the commissioner to promulgate administrative regulations, to require the commissioner to appoint an advisory committee to advise in the development of the Independent Health Care Appeals Program; create a new section of KRS 304.17A to require the commissioner to report every six (6) months to the Interim Joint Committee on Banking and Insurance and to the Governor on the status of the Independent Health Care Appeals Program; amend KRS 304.17A-505 to delete references to KRS 211.464(1)(g); and to repeal KRS sections 211.461 to 211.466.

(Prefiled by the sponsor(s) indicated with recommendation for passage, and as amended by the Interim Joint Committee on Banking and Insurance)